Provider Demographics
NPI:1336173095
Name:ROCHE A CRI CLINIC SC
Entity type:Organization
Organization Name:ROCHE A CRI CLINIC SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-339-3326
Mailing Address - Street 1:P.O. BOX 10
Mailing Address - Street 2:
Mailing Address - City:FRIENDSHIP
Mailing Address - State:WI
Mailing Address - Zip Code:53934-0010
Mailing Address - Country:US
Mailing Address - Phone:608-339-3326
Mailing Address - Fax:608-339-6057
Practice Address - Street 1:302 W. LAKE ST.
Practice Address - Street 2:
Practice Address - City:FRIENDSHIP
Practice Address - State:WI
Practice Address - Zip Code:53934
Practice Address - Country:US
Practice Address - Phone:608-339-3326
Practice Address - Fax:608-339-6057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32742100Medicaid
WI43055000Medicaid
WI32742100Medicaid
WI523837Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC